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Findings library
MajorChapter 1 25 Aug 2026

The change that went live before anyone approved it

Change control: change implemented prior to approval

What the inspector wrote

Change control CC-24-031 to replace the filling machine PLC was raised on 14 March and approved on 2 April. Maintenance records show the PLC was replaced on 21 March and production resumed on 22 March. Three batches were manufactured on the modified equipment before the change control, including its validation impact assessment, was approved.

Cited against EU GMP Chapter 1, 1.4(xiii); Annex 15, 11

Why it was cited

The point of change control is that the assessment happens before the change. Implementing first and approving later turns the assessment into paperwork, and it means product was made on equipment whose validated state was, at that moment, unknown.

This finding almost always arrives with a second one: the batches made in the gap were released without a deviation being raised.

What would have prevented it

  • Engineering and maintenance work orders that touch GMP equipment should require an approved change control number before work can be scheduled.
  • Define clearly what counts as like-for-like, and have QA agree the classification, so urgent repairs have a fast lane that is still controlled.
  • Batch release should include a check for open or recently approved changes on the equipment used.

Written from the deficiency categories published by EU and UK regulators. Details are illustrative and do not describe a specific named site.

More findings

MajorChapter 1 15 Sept 2026

'Human error' accepted as a root cause, again

Investigation of anomalies: inadequate root cause analysis

Deviation DEV-24-0187 concluded that the root cause was operator error and the CAPA was retraining of the operator concerned. The same failure mode had been recorded in three previous deviations in the preceding fourteen months, each with the same conclusion and the same corrective action. No assessment of contributing factors, procedure design or equipment had been performed.

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MajorChapter 1 8 Sept 2026

The impact assessment that stopped at the batch

Deviation handling: impact on other batches not evaluated

A temperature excursion in cold store CS-02 was recorded as a deviation against batch 4471 only. Twelve other batches of four products were stored in CS-02 during the excursion window. No assessment of impact on these batches was performed and two of them were subsequently certified and distributed.

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MajorChapter 4 1 Sept 2026

Shared logins on a GMP system

Computerised systems: data integrity, access control

The chromatography data system in QC laboratory 2 was accessed using a shared account 'QCLAB' whose password was known to all analysts. Electronic signatures applied under this account could not be attributed to an individual. The audit trail showed 214 result approvals under the shared account in the review period.

Read the breakdown